Saudi Journal of Gastroenterology
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CASE REPORT Table of Contents   
Year : 1997  |  Volume : 3  |  Issue : 1  |  Page : 56-59
Gastrointestinal bleeding from the jejunal metastatic choriocarcinoma: A case report


1 Department of Gastroentrology, King Fahad Hospital, Madina Al-Munawarah, Saudi Arabia
2 Deparatment of Gastroentrology, King Abdul Aziz Hospital and Oncology Center, Jeddah, Saudi Arabia

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Date of Submission19-Dec-1995
Date of Acceptance02-Jun-1996
 

How to cite this article:
Khawaja FI, Barlas S. Gastrointestinal bleeding from the jejunal metastatic choriocarcinoma: A case report. Saudi J Gastroenterol 1997;3:56-9

How to cite this URL:
Khawaja FI, Barlas S. Gastrointestinal bleeding from the jejunal metastatic choriocarcinoma: A case report. Saudi J Gastroenterol [serial online] 1997 [cited 2021 Aug 4];3:56-9. Available from: https://www.saudijgastro.com/text.asp?1997/3/1/56/33948


Overt gastrointestinal bleeding originating in the small intestine is uncommon. The usual clinical presentation is in the form of melena without hematemesis. Benign lesions characteristically cause massive and repeated bouts of bleeding whereas minor and occult bleeding is common with malignant lesions of the small bowel. An unusual case of choriocarcinoma metastatic to the small bowel is reported here. The atypical presentation as massive gastrointestinal hemorrhage, its diagnosis and management are discussed.


   Case report Top


A 25-year-old lady was admitted with a one month history of intermittent black, tarry stools. There was no associated hematemesis or hematochezia. Two years ago she had a molar pregnancy. Six months after the evacuation of the hydatiform mole she conceived and subsequently delivered a healthy baby at full term. On examination she was found to be pale and apprehensive. Her pulse was 110/minutes, supine blood pressure was 140/80 mm Hg, which on standing dropped to 110/70 mm Hg. There was no stigmata of chronic liver disease. Examination of the abdomen and other systems was unremarkable. Rectal examination confirmed the presence of melenic stool .

Her hemoglobin on admission was 4 g%, white cells count and platelets count were normal. Blood urea nitrogen was elevated to 72 mg% with normal serum creatinine. Serum bilirubin, transaminases, alkaline phosphatase, coagulation profile were within normal limits. Roentogram of the chest revealed a 4 x 4 cm cannon ball lesion in the right lower lung field. She was stabilized with IV fluids, colloids and blood transfusions. A panendoscopy up to the ligament of the Treitzs was normal. On colonoscopy altered blood was present in the entire colon, however no bleeding site or pathology was noted. Barium meal and follow up examination was of no help. Facilities for radioisotope technetium 99 scan and angiography were not available.

On the third day she started passing frequent melenic stools and subsequently became hypotensive. An urgent laparotomy was carried out after resuscitation. A small ulcerating nodule was found 25 cm from the duodeno-jejunal junction. Local resection of this actively bleeding lesion with end to end anastomosis was carried out. Unfortunately, she had to be re-explored because of recurrent and massive bleeding on the second postoperative day. After the abdomen was opened the small bowel was examined. A small caliber Olympus P10 endoscope was introduced through a small enterostomy in the upper jejunum.

The entire small bowel was inspected from inside and at the same time transilluminated. After meticulous examination three lesions were identified and marked. No active bleeding was noted. A purplish lobulated mass 1.5 x 2 cm in size was noted at 15 cm from the duodeno jenunal junction. The overlying mucosa was ulcerated [Figure - 1]. The other two lesions were small 0.3 x 0.3 cm in size. The site of previous anastomosis was not bleeding. The segment of jejunum containing all the three lesions was resected and the continuity of bowel was restored by an end-to-end anastomosis. The subsequent clinical course was uneventful.

Microscopic examination of resected bowel revealed a submucosal infiltrating tumor eroding through a normal intestinal mucosa [Figure - 2]. The tumor composed of malignant trophoblastic tissue with abnormal proliferation of cubodial and cyncitial cells. The findings were consistent with a metastatic choriocarcinoma.

The human chorionic gonadotropin hormone (HCG) levels in the blood were elevated to 190,000 IUhnl. Whole body computerized tomographic scanning revealed the evidence of metastasis in the liver, retroperitoneal lymph nodes, right lung and brain. A thorough gynecological examination was unremarkable. Endometrial tissue obtained via curettage revealed no evidence of choriocarcinoma.

Several courses of chemotherapy with actinomycin-D, methotrexate, chlorambucil combined with cranial irradiation were administered. A complete clinical and radiological regression of the disease was achieved and the human chorionic gonadotropic hormone could not be detected in the blood anymore. During a one-year follow up she remained disease free.

There after the patient left for Syria and no further follow up was available [Figure - 1],[Figure - 2].


   Discussion Top


The causes of the small bowel hemorrhage include tumors [1] , Meckel diverticulum [2] , Arteriovenous Malformation [3],[4] , Lymphangiectasia [5] , small bowel Crohn's Disease, [6] , Radiation Ileitis, Vasculitis and Collagen Disorders such as Polyarteritis Nodosa [Table - 1]. Primary tumors of the small bowel are rare and constitute about 5% of all tumors of the alimentary tract where as metastatic implants are seen frequently. Metastasis to the small intestine reach either by direct extension from nearby structures or by way of lymphatic or blood vessels from more distant sites. Metastatic lesions of small bowel are typically multiple and ulcerating [7] . Melenoma is the most common metastatic tumor to the small bowel. As the small bowel lacks melanocytes, melanoma is never primary in the small bowel [7] .

Benign lesions of small bowel characteristically cause massive and repeated bouts of bleeding where as in the malignant lesions the bleeding is usually minor or occult [7] .

Fortunately bleeding is an uncommon presentation of small bowel tumors and only 10% of such patients are admitted with intestinal blood loss. The tumors responsible for bleeding include, leiomyoma, hemangioma and carcinoma [8] .

Choriocarcinoma metastases to the small bowel are rare. In a review of 988 cases of the gestational trophoblastic disease, metastatic deposits were seen in only 127 cases (12.85 %). Lungs, vagina and brain were the most frequent sites of metastasis in decreasing frequency. Only three cases of intestinal metastasis were noted [9] . In about 90% of the patients who have had a hydatiform mole, the trophoblastic tissue dies out spontaneously after the uterus has been removed. In the remaining 10% the trophoblastic tissue may persist or recur as invasive mole or choriocarcinoma [10] . The antecedent pregnancy is a hydatiform in about 50% of cases if choriocarcinoma, a normal pregnancy in 26% and an abortion or ectopic pregnancy in about 17% [10] . The risk of choriocarcinoma, after a hydatiform mole is 2-4 percent, which is about 1000 times greater than after a normal pregnancy. Our case was likely due to metastasis from hydatiform mole, however possibility of its origin from the preceding normal pregnancy cannot be ruled out.

Continuous follow up and surveillance are recommended for two years after molar evacuation by estimations of urinary or blood HCG levels. The overall prognosis for choriocarcinoma is good and five years survival rate is around 94% [10] .

Small bowel bleeding is a challenge for gastroenterologists because the source of hemorrhage may remain obscure despite exhaustive workup. Different diagnostic modalities are available for investigating the small bowel bleeding. A methodical approach may save many unnecessary procedures [11] .

The small bowel barium follow up examination may readily recognize narrow constricting lesions, round intraluminal defects or polypoidal infiltrations but flat mucosal lesions are always missed. Small bowel visualization by the enteroclysis has a higher diagnostic yield however the procedure is lengthier and more invasive [12] . Barium studies have no usefulness during active phase of bleeding. In our patient barium follow up was unremarkable.

Radioisotope scintigraphy is of help in the evaluation of bleeding from the gastrointestinal tract. Technetium - 99 m pertechetate scan may be of value in diagnosis of a bleeding Meckel diverticulum may take up the nuclide. A tagged red blood cell bleeding study is more useful in search of a source of active bleeding [13] .

A leak as small as 05-1 ml/minute can be recognized and it is possible to locate the site of lower gastrointestinal bleeding in about 50% of patients [14] . However, it cannot reveal the type of lesion.

Small intestinal angiography is most useful in the search for the site and cause of actively bleeding lesion and in documenting the presence of angiodysplastic lesions [15] . Angiography often demonstrate the site of bleeding when the rate of blood loss exceeds 1-2 ml/minute. For better diagnostic yield a positive tagged RBC scan is usually recommended before doing superior mesenteric artery angiography and subelective angiography.

Small bowel endoscopy (Enteroscopy) is a useful tool for the evaluation of small intestinal bleeding of obscure origin [16] . Approximately one-third of bleeding patients are found to have a responsible lesion in the small intestine, most commonly angiodysplastic lesions [17] . Such localization is of great benefit to surgeons if surgery is contemplated. Electro­coagulation may be effective in some selected cases thus avoiding the need for surgery.

Intraoperative endoscopic transillumination of the entire small bowel can be performed. The surgeon introduces the scope via an enterostomy and guides it through the bowel [18] . The bowel is then carefully examined as the endoscopic light transilluminates. A better visualization is obtained if all the external light sources are dimmed [19],[20] .

Small bleeding lesions and ulcerations commonly elude diagnosis by a routine exploration laparotomy and this may be extremely frustrating for both the patient and the physician. Such lesions can be easily identified by transillumination as demonstrated in the case presented.

 
   References Top

1.Middletan WRJ. "Acute Gastrointestinal Bleeding". Clinical diagnosis of Gastrointestinal Disease.Blackwell Scientific Publications 1981;Chapter 6, PP 45.  Back to cited text no. 1    
2.Seagram CGF, Louch RE, Stephens CA et al. M e c k e l ` s diverticulum : a 10-year review of 218 cCanJ Surgery 1968;11:369-73.  Back to cited text no. 2    
3.Marx FW, Gray RK, Duncan AM et al. Angiodysplasia as a source of intestinal bleeding Am J Surgery 1977;134:12530.  Back to cited text no. 3    
4.Jacobson G, Krause V. Hereditary Hemorrhage telengiectasia localized to Gastrointestinal Tract. ScandGastroenterol 1970;5:283-8.  Back to cited text no. 4    
5.Poirier VC, Alfidi RJ. Intestinal Lymphangiectasia associated with Fatal Gastrointestinal Bleeding. Am J Dig Dis 1973;18:54-8.  Back to cited text no. 5    
6.Sunkwa-Mills HNO Life threatening hemorrhage in Crolm`s Disease. Br J Surgery 1974;61:291-2.  Back to cited text no. 6    
7.Spiro HM. Tumors of Small Intestine. Text Book of Clinical Gastroenterology 3rd Edition 1983.  Back to cited text no. 7    
8.Macmillan 643-666. Botsford TW, Grove P, Crocker DW Tumors of small intestine. Am J Surg 1962;103:358-65.  Back to cited text no. 8    
9.Kunar J, Ilancheran A, Ratnam SS. Pulmonary Metastasis it Gestational Trophoblastic Disease: A review of 97 cases Brit J OBs/Gyne 1988;95:70-4.  Back to cited text no. 9    
10.Howie PW. Trophoblastic Disease. Dewhurst Text Book of Gynecology, 4th edition, Blackwell Scientific Publications 1986:37;556-67.  Back to cited text no. 10    
11.Levine JS. Recurrent Gastrointestinal Bleeding of Uncertain site - Decision making in Gastroenterology 2nd Edition 1992 B.C. Decker 124-5.  Back to cited text no. 11    
12.Rex DK, Lappas JC, Maglinte DD et al. Enterocylsis in the evaluation of suspected small intestinal bleeding. Gastroenterol 1989;97:58-62.  Back to cited text no. 12    
13.Markisz JA, Front D, Royal HD et al. An evaluation of 99 m to labeled red blood cell scintigraphy for the detection and localization of gastrointestinal sites. Gastroenterol 1982;83:394-8.  Back to cited text no. 13    
14.Alavi A, Ring E. Localization of Gastrointestinal Bleeding. Am J Roentgenol 1981;137:741-8.  Back to cited text no. 14    
15.Tillotson CL, Geller SC, Kantrowitz et al. Small bowel hemorrhage: angiograhic localization & intervention. Gastrointest Radiol 1988; 13:207-11.  Back to cited text no. 15    
16.Way DJ. Small Bowel Endoscopy. Endoscopy 1992;24:68-72.  Back to cited text no. 16    
17.Lewis BS, Waye JD. Chronic Gastrointestinal Bleeding of Obscure Origin: Role of bowel endoscopy. Gastroentrtol1988;94:1117-20.  Back to cited text no. 17    
18.Schein M, Decker G. Retrograde intra-operation. endoscopy in Obscure bleeding of the Gastrointestinal Tract. Surgery Gynecol Obstet l988:167-73.  Back to cited text no. 18    
19.Fierst SM, Khawaja Fl, Levowitz B. Intraoperative Endoscopy with transillumination to locate site of hemorrhage. Am J Gastrointest Endosc 1990;26:65.  Back to cited text no. 19    
20.Fierst SM, Khawaj a FI Levowitz B. Intraoperative Endoscopy with Transillumination to locate site of hemorrhage. Am J Gastroenterol 1981;76:176.  Back to cited text no. 20    

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Correspondence Address:
Shahid Barlas
King Abdulaziz Hospital and Oncology Center, P.O. Box 31467, Jeddah 21497
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


PMID: 19864816

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